Diabetes Care

Diabetes Care
The overriding principle is to teach patients how to live "with" their diabetes rather than "for" diabetes. We emphasize teaching patients the latest management techniques, whether in nutrition, weight loss, physical activity, medications, blood glucose monitoring, or insulin delivery. We know that diabetes "takes no vacation" and, therefore, we give our patients the tools they need to handle any situation they might encounter in their daily lives. This patient education and empowerment is an ongoing and time-consuming process. We remain committed to each individual patient to assure they feel comfortable with their diabetes management.
The bottom line is achieving blood glucose levels which are as close to normal as safely possible to avoid diabetic complications.

Targets in diabetes treatment
For patients checking their blood glucose levels, the American Diabetes Association guidelines call for preprandial (before meals) capillary plasma glucose 90–130 mg/dl (5.0–7.2 mmol/l), peak postprandial (after meals) capillary plasma glucose under 180 mg/dl and 100 -140 mg/dl at bedtime. The long-term control is assessed by a test called A1c, which should be less than 7% (healthy people have a level under 6%); in selected patients the goal should be normal glucose level; i.e. A1c under 6%. The American College of Endocrinology suggests A1c at or below 6.5%, premeal glucose under 110 mg/dl and 2-hour after meal glucose of under 140 mg/dl.

Insulins
Insulin is a hormone necessary for survival. It regulates our metabolism (of carbohydrate, protein and fat) in countless ways. Patients with type 1 diabetes make none and, to survive, need to give themselves insulin every day (usually 3-4 times a day or through a continuous insulin infusion pump). Those with type 2 diabetes make too little insulin and secrete it usually too late to successfully cover their meal-related insulin demands. Thus, many persons with type 2 diabetes find it necessary to administer insulin, too (often alongside some of the anti-diabetic pills). Insulin cannot be ingested by mouth since the stomach juices would destroy it. In order to bypass the stomach, insulin is typically injected through the skin via a skinny (30 or 31-gauge) needle. Theoretically, it could also be given in any number of other ways (by inhalation into lungs, by applying on oral or nasal mucosa, by a skin patch or by a rectal suppository).

Rapid-Acting Insulins
These insulin preparations are injected at mealtimes usually in proportion to the carbohydrate content of the meal. They act quickly (within 15 minutes), reach their maximum effect in 1.5 to two hours and last for a total of about four hours. These insulins are represented in the U.S. market by LisPro (Humalog®), aspart (Novolog®), and glulisine (Apidra®).

Short-Acting Insulins
The only one used in the U.S. is Regular insulin. It is injected 30 - 45 minutes before meals. It takes about one hour to start working, and its effect lasts about four to six hours.

Intermediate-Acting Insulins
These insulins take four to six hours to start working and maintain their blood-sugar lowering effect for up to 14 to 16 hours. They are typically injected twice daily - in the morning and in the late evening or at bedtime. Because of their prolonged effect, their use is not tied to meals. NPH (N, cloudy) is a representative of this class.

Long-Acting Insulins
Glargine (Lantus®) and detemir (Levemir®) insulins are up to 24-hour lasting, relatively peakless insulins. They are usually injected once a day. They reach their effects within one to two hours and maintain a reasonably steady effect throughout the entire day. In some patients, the need to be injected twice daily to avoid low sugar reactions.

Ultralente (UL) insulin is used uncommonly nowadays. Its effect and duration are highly variable, typically lasting 24 - 36 hours.

Pre-mixed insulins
In many cases, physicians and their patients find it more convenient to use one of several pre-mixed insulin combinations. These are mixtures of either rapid-and intermediate-acting insulins (such as 25% Humalog & 75% NP-Humalog, 50% Humalog & 50% NP-Humalog or 30% Novolog & 70% NP-Novolog) or short- and intermediate-acting mixtures (such as 30% Regular & 70% NPH or 50% Regular & 50% NPH).

Insulin Injection Devices
Insulin can be injected either by a special syringe which the patient fills with appropriate amount of the specific type of insulin or by an insulin pen. The pen devices are either disposable (prefilled with 150 or 300 units of insulin) or permanent into which prefilled insulin cartridges are fitted. Needle-less devices also exist. These inject insulin through the skin under pressure.

Insulin Pumps
Insulin can also be delivered under the skin by continuous infusion from an external pump (about the size of a pager). The syringe inside the pump usually holds 300 units of insulin. Insulin is pumped through thin, plastic tubing, ending in a needle under the skin. These external pumps (in the U.S. most are marketed by Medtronic MiniMed, Smiths/Deltec, Disetronic/Roche, Animas or OmniPod/Insulet) cannot read blood glucose levels. Thus, the patient still has to monitor his or her own sugars to be able to adjust insulin infusion rates ("basal" rates and mealtime "boluses"). The recently introduced Paradigm 522/722 is the first insulin pump wirelessly integrated with a continuous glucose sensor.

Implantable Insulin Pumps
These pacemaker-like devices infuse insulin into the peritoneal space (not under the skin). A remote-control device adjusts infusion rates. These pumps have been used in Europe for about two decades but remain 'experimental" in the USA.

Oral Medications
Oral medications are used in type 2 diabetes.

  1. Drugs delaying glucose absorption from small intestine
    • acarbose (Precose®) and miglitol (Glyset®). These are used with meals in an attempt to lower post-meal hyperglycemia.
  2. Drugs increasing insulin secretion
    • short-acting - repaglinide (Prandin®) and nateglinide (Starlix®). These are used with meals to reduce post-meal sugar levels.
    • long-acting - sulfonylureas, such as glipizide (Glucotrol®), glyburide (Micronase®, Diaßeta®) and glimepiride (Amaryl®). These medications are used once or twice daily to lower overall, but especially overnight, sugar levels.
  3. Drugs improving insulin action

    4. These medications help body organs (skeletal muscles, liver, fat) to make better use of insulin in the patients' bodies.

    • biguanides - metformin (Glucophage®) has major effect on the way insulin works on the liver to decrease the amount of sugar the liver makes. Metformin cannot be used if the patient's kidneys do not work properly.
    • thiazolidinediones - (also called glitazones) - rosiglitazone (Avandia®) and pioglitazone (Actos®) - help insulin to work especially on muscles and fat. They are long-acting, usually used once a day. They cannot be used when the patient has significant congestive heart failure.
  4. Drugs preserving the "incretin" effect

    5. These medications block the enzyme (DPP-4) which breaks down incretin hormones released from small intestine after we eat. This way, they prolong the incretin effect helping to release more insulin and decrease the amount of sugar made by the patient's own liver.

    • Januvia (sitagliptin) is currently the only one on the U.S. market.
  5. Drugs combining effects
    These medications combine the insulin-action improving and insulin-secreting effects of the above-mentioned drugs.
    • Avandamet (combination of Avandia and metformin)
    • Avandaryl (combination of Avandia and Amaryl/glimepiride)
    • Glucovance (combination of glyburide and metformin)
    • Metaglip (combination of glipizide and metformin)
    • ACTOplus Met (combination of Actos and metformin)
    • Duetact (combination of Actos and Amaryl/glimepiride)
  6. Symlin® (pramlintide)
    When a healthy person eats, pancreatic beta cells make two hormones to handle the dietary load: insulin and amylin. We have provided patients with mealtime insulin since 1922. It has been only since 2005 that we have been able to provide the other necessary hormone: amylin. Amylin normally complements insulin's effects: it works through brain and decreases the amount of your own sugar made by the liver (you don't need it since you are eating), it slows stomach emptying thus decreasing the sugar spikes after meals, and it increases the sense of satiety and decerases appetite - patients wind up eating less before they feel full.Symlin® is a synthetic version of human amylin. Since amylin is made by the same cells as insulin, it stands to reason that patients with type 1 diabetes make none and those with type 2 diabetes make too little of it. Symlin® is, therefore, given by patients with either type 1 or type 2 diabetes (through the usual small insulin syringe) at mealtime alongside their rapid-acting insulin (they cannot be mixed together in the same syringe). The possible advantages of using Symlin ® are better, smoother glucose control (while using less mealtime insulin), and weight loss.
  7. Byetta® (exenatide)
    Several other hormones are also normally released from the stomach and small intestine when we eat. They are called "incretins". Byetta® is the first synthetic analog of an important human incretin (glucagon-like peptide 1 or GLP-1) approved by the FDA in 2005 to be used in the U.S. by patients with type 2 diabetes to improve glucose control. This hormone, injected by a pen device twice daily (before breakfast and before dinner), acts at four different places: it tells the pancreatic islet beta cells to make more insulin at mealtimes; it tells the pancreatic islet alpha cells to make less glucagon (which in turn means your liver will make less sugar at mealtime); it tells the stomach to slow down its emptying (so there is less sugar spike after meals) and finally, it tells the brain that you are full, decreasing appetite and food intake (through a different mechanism from Symlin®). As a result, patients can achieve better diabetes control, sometimes can decrease the amount of pills they take for sugar control, and can experience significant weight loss.

Diet/Nutrition

Diet remains by far the most important aspect of diabetes treatment. Because at least 90% of patients with type 2 diabetes are overweight or obese, most diets need to be also weight-losing ones (usually aimed at ½ - 1 lb. weight loss each week). However, even patients with type 1 diabetes and nonobese people with type 2 diabetes have to stay on proper diet for life. Proper nutrition, regular meal-time schedules, adequate supply of necessary nutrients, vitamins and minerals have to be matched with the patient's overall health status, age, medications, work activity and schedule, cultural and social backgrounds and habits, etc. Given these complexities, it is mandatory that patients undergo intensive education about diet with dietitians or nutritionists specializing in diabetes care. Further, because there are constantly new developments in our understanding optimal diet management, patients need to get refresher courses in nutrition at least every couple of years.

Physical Activity/Exercise
Physical activity goes hand in hand with diet as the cornerstone of diabetes management. Just as dietary advice, proper physical activity education needs to take into account patient's age, physical status, other illnesses, medications patient is taking, daily schedule, etc., etc. It needs to be given by personnel experienced in dealing with the effects of exercise on blood sugar levels, especially in those on insulin or other medications capable of lowering glucose levels below normal.

Proper exercise routine is intended to improve the way insulin works in patients' bodies and improve their cardiovascular fitness. Exercise alone cannot be expected to lead to significant weight loss. To achieve the desired effects, patients should exercise three to five times per week at about 60 to 75% maximum intensity for about 45 minutes each time. Exercise should include both aerobic (jogging, brisk walking, swimming, biking) and anaerobic (strengthening, weight lifting) types of activity. Proper stretching, warming up and cooling down is also essential in order to assure benefits of exercise and to avoid injuries.

*BALANCE YOUR FOOD INTAKE AND YOUR ACTIVITY* (adapted from the U.S. Surgeon General Report on Overweight and Obesity)
Reducing your calorie intake by 150 calories a day, along with participating in moderate activity, could double your weight loss and is equivalent to approximately 10 pounds in 6 months and 20 pounds in 1 year.
* One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes.
* The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie could be about 40 minutes of raking leaves (200 calories).
* One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is in one jelly filled doughnut (300 calories).
* A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is equal to running 2½ hours at a 10 min/mile pace (1500 calories).